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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610270
Report Date: 12/27/2022
Date Signed: 12/27/2022 12:48:08 PM

Document Has Been Signed on 12/27/2022 12:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SKYVIEW ASSISTED LIVINGFACILITY NUMBER:
197610270
ADMINISTRATOR:HULSE, BREANNAFACILITY TYPE:
740
ADDRESS:18761 BIG CEDAR DRIVETELEPHONE:
(661) 965-4652
CITY:SANTA CLARITASTATE: CAZIP CODE:
91387
CAPACITY: 6CENSUS: 0DATE:
12/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Breanna Hulse, AdministratorTIME COMPLETED:
01:20 PM
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At 10:45am Licensing Program Analysts (LPA) Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with applicant Skyview Assisted Living, LLC. LPA conducted an entrance interview with the Administrator.

Fire Clearance dated 10/18/2022 was received for six (6) non-ambulatory residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has a total of four (4) bedrooms, four (4) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility designated for resident use and were observed to have non-skid mats and appropriate grab bars installed. The facility will have awake staff at night.

The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. The fire extinguisher is located in the living room area and was observed to be fully charged and was purchased on 10/17/2022. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:20am they were tested and observed to be operational. At 11:30am the hot water was tested and measured at 115.0°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the dining room wall with other posting requirements. Medications will be stored in a locked cabinet in the kitchen. The first aid kit is readily available. Resident and staff records will be stored in a locked cabinet in the office. The kitchen knives are stored in a locked toolbox inside the locked cabinet near the living room. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the laundry area. Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SKYVIEW ASSISTED LIVING
FACILITY NUMBER: 197610270
VISIT DATE: 12/27/2022
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The laundry area is located by the office. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house and is currently being used as an emergency and perishable food and other supplies storage. The garage was observed to be locked. There is no body of water in the facility.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Licensee Representative Breanna Hulse and a copy of this report was provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC809 (FAS) - (06/04)
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